Unpacking the implementation blackbox using 'actor interface analysis': how did actor relations and practices of power influence delivery of a free entitlement health policy in India?

Rakesh Parashar,Nilesh Gawde,Anadi Gupt,Lucy Gilson

doi:10.1093/heapol/czaa125

Abstract

Exploring the implementation blackbox from a perspective that considers embedded practices of power is critical to understand the policy process. However, the literature is scarce on this subject. To address the paucity of explicit analyses of everyday politics and power in health policy implementation, this article presents the experience of implementing a flagship health policy in India. Janani Shishu Suraksha Karyakram (JSSK), launched in the year 2011, has not been able to fully deliver its promises of providing free maternal and child health services in public hospitals. To examine how power practices, influence implementation, we undertook a qualitative analysis of JSSK implementation in one state of India. We drew on an actor-oriented perspective of development and used ‘actor interface analysis’ to guide the study design and analysis. Data collection included in-depth interviews of implementing actors and JSSK service recipients, document review and observations of actor interactions. A framework analysis method was used for analysing data, and the framework used was founded on the constructs of actor lifeworlds, which help understand the often neglected and lived realities of policy actors. The findings illustrate that implementation was both strengthened and constrained by practices of power at various interface encounters. The implementation decisions and actions were influenced by power struggles such as domination, control, resistance, contestation, facilitation and collaboration. Such practices were rooted in: Social and organizational power relationships like organizational hierarchies and social positions; personal concerns or characteristics like interests, attitudes and previous experiences and the worldviews of actors constructed by social and ideological paradigms like their values and beliefs. Application of ‘actor interface analysis’ and further nuancing of the concept of ‘actor lifeworlds’ to understand the origin of practices of power can be useful for understanding the influence of everyday power and politics on the policy process.

Highlights

Implementation of health policies is the blackbox that holds many answers to the questions of how policies can meet their intent and how intended users of the policy see them in practice
Implementation decisions and actions in Janani Shishu Suraksha Karyakram (JSSK) experience were influenced by a complex interplay of practices of power which were underpinned by lived social realties or the lifeworlds of the actors
Everyday politics and power struggles of actors in this experience reinforced the idea that implementing health policies is not a function of merely having an implementation blueprint

Summary

Introduction

Implementation of health policies is the blackbox that holds many answers to the questions of how policies can meet their intent and how intended users of the policy see them in practice. All policy processes are contingent on wider socio-political contexts and are shaped by the interaction of involved actors, their knowledge and power dynamics, as well as by aspects of decision making and the policies in question (Walt and Gilson, 1994). The implementation of health policies has been less commonly studied for understanding the influence of actors’ agency and power, their interactions and relationships and how actors assemble the surrounding structures and contexts in LMICs (Sheikh and Porter, 2010; Lehmann and Gilson, 2013; Sheikh et al, 2014; Barasa et al, 2016) and respond to implementation needs

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